- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.19 / $2,813.68 / $2,813.68
| Professional | | $2,249.19 | $2,813.68 | $2,813.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.19 / $2,592.00 / $3,993.75
| Professional | | $2,203.19 | $2,592.00 | $3,993.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,249.19 / $2,813.68 / $3,376.42
| Facility | | $2,249.19 | $2,813.68 | $3,376.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.10 / $3,473.10 / $3,473.10
| Professional | | $3,473.10 | $3,473.10 | $3,473.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.83 / $1,573.72 / $2,554.60
| Professional | | $1,143.83 | $1,573.72 | $2,554.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $3,307.70
| Facility | | $100.00 | $100.00 | $3,307.70 |